Ill. Admin. Code tit. 77, pt. 694, subpt. C, app C
Current through Register Vol. 48, No. 45, November 8, 2024
1. Name
2. Student Identification Number
3. Month, Day and Year of Birth
4. Gender
5. Term and Year of First Entry
6. Dates to Establish Immunity to Measles (Rubeola)
7. Dates to Establish Immunity to Rubella
8. Dates to Establish Immunity to Mumps
9. Dates to Establish Immunity to Tetanus/Diphtheria
10. Date of Most Recent Tetanus/Diphtheria/Pertussis Booster (Tdap)
11. Date of Most Recent Meningococcal Vaccine
12. Phone Number of Certifying Health Care Provider
13. Name and Signature of Health Care Provider
Ill. Admin. Code tit. 77, pt. 694, subpt. C, app C